https://doi.org/10.5125/jkaoms.2017.43.3.197 TECHNICAL NOTE pISSN 2234-7550·eISSN 2234-5930 Modified drainage of submasseteric space abscess Moon-Gi Choi1,2 1Department of Oral and Maxillofacial Surgery, College of Dentistry, Wonkwang University, 2Wonkwang Dental Research Institute, Wonkwang University, Iksan, Korea Abstract (J Korean Assoc Oral Maxillofac Surg 2017;43:197-203) Once a submasseteric space infection is diagnosed, the key to resolving the infection is via surgical intervention to evacuate the pus. Although it is pos- sible and occasionally practical to drain the submasseteric space via an intraoral approach, an extraoral approach may sometimes be required. Surgeons have encountered complications such as facial nerve damage during extraoral incision and drainage procedures, and they have felt that extraoral dissec- tion was very difficult. As such, an easier and simpler technique is needed. Our department recently modified various drainage techniques for submas- seteric space abscesses. Damage to the marginal branch of the facial nerve did not occur, and this technique was very simple and rapid, such that a nov- ice physician could perform this procedure. This modified technique was possible with trismus and under local anesthesia. After intraorally checking the position of the drain, the intraoral wound is closed with an absorbable suture and the drain is fixed to the extraoral skin. When a masseteric space infection is diagnosed, multiple space involvement is ruled out, and dependent drainage is required, this modified drainage technique can be useful. Key words: Submasseteric space abscess, Modified drainage [paper submitted 2016. 8. 31 / revised 2017. 1. 15 / accepted 2017. 2. 5] I. Introduction a small insertion that is limited to the lateral surface of the coronoid process and upper third of the ramus of the man- The submasseteric space is one of three spaces that make dible. The superficial portion has the largest insertion point up the main masseteric space, the other two being the tem- that is restricted to the lower third of the ramus, specifically poral and the pterygomandibular spaces. It is formed by the posterior angle of the mandible. The middle portion was splitting the superficial layer of the deep cervical fascia that the smallest and inserted along a thin line curving posteriorly encloses the mandible and primary muscles of mastication. and superiorly over the middle third of the ramus2. The contents of this space include the masseter muscle, the Bransby-Zachary2 demonstrated a true submasseteric space ramus and posterior body of the mandible, the tendinous in- lateral to the mandibular ramus, which is a bare area between sertion of the temporalis muscle, the medial and lateral ptery- the separate attachments of the deep and middle portions of goid muscles, and the inferior alveolar nerve and vessels1. the masseteric muscle, thus resulting in a potential space. As The masseter muscle is divided into three parts: superficial, such, the submasseteric space is located between the laterally middle, and deep. All three parts originate from the zygo- placed, thick, quadrate master muscle and the mandibular ra- matic arch. Bransby-Zachary2 found that the deep portion has mus, which represents the medial border3. Once a submasseteric space infection is diagnosed, the key Moon-Gi Choi first step in resolving the infection is surgical evacuation of Department of Oral and Maxillofacial Surgery, College of Dentistry, Wonkwang the pus4,5. Although it is possible and occasionally more prac- University, 460 Iksan-daero, Iksan 54538, Korea tical to drain the submasseteric space intraorally, sometimes TEL: +82-63-859-2921 FAX: +82-63-859-4002 E-mail: [email protected] it may be more prudent to gain access via an extraoral ap- ORCID: http://orcid.org/0000-0003-3502-7652 proach6. As an alternative, some have suggested an extraoral CC This is an open-access article distributed under the terms of the Creative Commons 7 Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), incision for drainage . which permits unrestricted non-commercial use, distribution, and reproduction in any Some surgeons have reported complications of facial nerve medium, provided the original work is properly cited. Copyright Ⓒ 2017 The Korean Association of Oral and Maxillofacial Surgeons. All damage during extraoral incision and drainage (I&D) proce- rights reserved. This paper was supported by Wonkwang University in 2016. 197 J Korean Assoc Oral Maxillofac Surg 2017;43:197-203 dures and have felt that extraoral dissection is very difficult. pacted third molar, as seen in the panoramic view.(Fig. 2) Thus, our department has recently simplified a submasse- On computed tomography (CT) examination, a pus collec- teric space drainage technique that has resulted in successful tion was found between the ramus and master muscle.(Fig. 3) abscess treatment. In this study, we report on this modified His complete blood count results included a total leukocyte drainage technique and incorporate literature reviews. count of 9,070 with 68.5% neutrophils and 22.2% lympho- cytes, hemoglobin level of 13.2 g/L, and a platelet count of II. Technical Note 164,000. The C-reactive protein and erythrocyte sedimenta- tion rate (ESR) test results were 98.23 mg/L and 9 mm/hr, 1. Case 1 respectively. The patient was diagnosed with a submasseteric space ab- A 27-year-old man visited the emergency room with tris- scess, and clamoxin and isepamicin were both administered. mus and painful swelling near the area of his left mandibular Under local anesthesia, I&D was done. After forcing the angle. He was only able to open his mouth 17 mm, and his mouth open, the vestibular mucosa was incised along the an- body temperature was 37.2°C. His pain was so severe that terior border of the masseter muscle. While the hemostat was the physician could not touch his swollen face. His left man- in contact with the lateral surface of the ramus, an additional dibular third molar had felt uncomfortable two days prior to hemostat was introduced through the intraoral wound and presentation, but the majority of symptoms developed the directed backwards. Through the intraoral route, the masseter morning of they presented to the emergency room. The cause muscle was detached from ramus as much as possible, which of infection was thought to be pericoronitis (Fig. 1) of the im- was performed more easily than anticipated.(Fig. 4) After detaching the masseter muscle from the ramus, a 1.0 cm horizontal incision was marked 2.0 cm below the lower border of the mandibular angle. The tip of hemostat was pushed toward the incision marking, lifting it up and allow- ing for incision of the elevated skin only. The tip of hemostat penetrated out through the incised skin.(Fig. 5) The drain was then attached to the hemostat and the hemo- stat was withdrawn. After checking the position of the drain intraorally, the intraoral incision was closed with absorbable Fig. 1. The patient exhibited swelling of the mandibular angle area. Moon-Gi Choi: Modified drainage of submasseteric space abscess. J Korean Assoc Oral Maxillofac Surg 2017 Fig. 2. The impacted third left, mandibular molar was thought to Fig. 3. On computed tomography scan, a pus collection was be the cause of infection. found between the ramus and master muscles. Moon-Gi Choi: Modified drainage of submasseteric space abscess. J Korean Assoc Oral Moon-Gi Choi: Modified drainage of submasseteric space abscess. J Korean Assoc Oral Maxillofac Surg 2017 Maxillofac Surg 2017 198 Modified drainage of submasseteric space abscess suture and the end of the drain was sutured to the skin with mild pain anterior to the left parotid gland for a total of five 6-0 nylon.(Fig. 6) The pus was sent for antibiotic sensitivity days. Although he had no fever, he appeared mildly ill on ex- testing and culture. amination. The patient was found to have a firm, tender mass Streptococcus salivarius was identified as the causative in the left cheek located anterior to the parotid gland and just organism. The drain was removed after being in place for ten superior to the mandible. On panoramic view, the retained days. The extraoral wound was left to heal on its own. The root of the second molar was thought to be the cause. He had patient was discharged after 14 days without complications. a mild trismus with the ability to open his mouth 20 mm. His complete blood count results included a total leukocyte 2. Case 2 count of 12,500 with 70.3% neutrophils and 17.8% lympho- cytes, a hemoglobin level of 12.6 g/L, and a platelet count of A 46-year-old man had symptoms of facial swelling and 410,000. C-reactive protein and ESR test results were 103.45 mg/L and 68 mm/hr, respectively. His blood glucose was 227 mg/dL. A CT scan revealed a thickening of the left masseter mus- cle, which was suggestive of cellulitis with abscess formation within the masseter muscle. Typically, submasseteric space abscesses will be found between the ramus and the master muscle, but in this patient, the abscess cavity was seen within the masseter muscle itself.(Fig. 7) The patient was diagnosed a submasseteric space abscess according Kay and Killey’s report5. Combicin, trizel and isepamicin antibiotics, along with amaryl, an antihypergly- cemic drug, were administered. The patient was sent to the operating room for drainage. The same I&D procedure, as Fig. 4. After incising the vestibular mucosa along the anterior border of the master muscle, a hemostat was introduced through described in Case 1, were performed under general anesthe- the intraoral wound and directed backwards. While the instrument sia. was in contact with the lateral surface of the ramus, the masseter The drain was removed after five days, and Staphylococ- muscle was detached from the ramus as much as possible.